COVID‐19 effect on patients with noncommunicable diseases: A narrative review

Abstract Background and Aims On March 11, 2020, the WHO has declared COVID‐19 a global pandemic, affecting our day‐to‐day lives. Physical distancing and lockdown made significant obstacles to populations, particularly healthcare systems. Most healthcare workers were reallocated to COVID‐19 facilities. Noncommunicable disease patients were given low priority and are at a higher risk of severe COVID‐19 infection, which disrupted the treatment and disease management of these patients. This review aimed to assess the effect of COVID‐19 on different types of noncommunicable diseases and the severity it may cause to patients. Methods We have conducted a review of the literature on COVID‐19 and noncommunicable diseases from December 2019 until January 2022. The search was done in PubMed and Cochrane for relevant articles using variety of searching terms. Data for study variables were extracted. At the end of the selection process, 46 papers were selected for inclusion in the literature review. Result The result from this review found that the COVID‐19 pandemic has affected the efficiency of the patient's treatment indirectly by either delaying or canceling sessions, which solidified the need to rely more on telemedicine, virtual visits, and in‐home visits to improve patient education and minimize the risk of exposure to the patients. The major and most common types of noncommunicable diseases are known to be related to the severe outcomes of COVID‐19 infection. It is strongly recommended to prioritize these patients for vaccinations against COVID‐19 to provide them with the protection that will neutralize the risk imposed by their comorbidities. Conclusion We recommend conducting more studies with larger population samples to further understand the role of noncommunicable diseases (NCDs) in this pandemic. However, this pandemic has also affected the efficiency of NCDs treatment indirectly by delaying or canceling sessions and others.


| INTRODUCTION
On March 11th, 2020, the COVID-19 global pandemic status was declared, having far-reaching implications on our daily lives. 1 Physical distancing and lockdown made significant obstacles to populations, particularly healthcare systems. Also, the lack of personal protective equipment, and more restrictions on healthcare providers and their contact with patients to reduce infection spread made it even harder on these patients. On the other hand, medical institutions were possible sources of infection which decreased the patients' willingness to seek care. 2 Most healthcare workers were re-allocated to  facilities. This caused the management of noncommunicable diseases (NCDs) to significantly scale down, especially during the initial pandemic outbreak, this caused NCD patients to be given low priority, and focused mostly on COVID-19 patients. It has been reported that NCDs are increasing the risk of severe COVID-19 infection conditions. 3 Also, their treatment plans and management of their diseases may have been affected because of their limited access to hospitals or clinics due to the pandemic.
In normal situations, NCDs count for 7 out of 10 of the major causes of premature deaths. 4,5 In the 21st century, between the ages of 30 and 69 years, there has been around 15 million premature deaths caused from NCDs (38%, 15/40 million). In addition, 85% of premature deaths occur in middle and low-income countries. 6,7 There are many different types of NCDs, however, the most common types are obesity, hypertension, diabetes, cardiovascular diseases (CVDs), chronic obstructive lung disease (COPD)/asthma, chronic kidney disease (CKD), and cancer. In fact, patients with obesity, diabetes, or CVD can have metaflammation and immunometabolism dysfunction, which can lead to disability, premature aging, and death. 8 Lifestylerelated diseases killed more people in the past than it is now.
However, the disease burden of type 2 diabetes and obesity continues to increase. In the USA, obesity is believed to be the a major reason that life expectancy is decreasing. 9 Most NCD medications play a role with the angiotensinconverting enzyme 2 (ACE2) receptor. ACE2 is a protein receptor that permits the access of COVID-19 virus into the cells and has been involved in the severity that diabetic and hypertensive patients experience when infected with the virus. The ACE2 is also found in the gastrointestinal tract, kidney, heart, and alveolar cells in the lungs.
Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are two types of renin-angiotensinaldosterone system (RAAS) inhibitors found in medications. 10 RAAS plays an important role in maintaining blood pressure. Angiotensin II is the effector molecule of RAAS, it is involved in the progression of CVDs, such as hypertension, myocardial infraction and heart failure. 11 ACEis and ARBs reduce the activity of angiotensin II by elevating the expression of ACE2. 12 Since ACEis and ARBs are found in the medications given to some NCD patients that have hypertension, diabetes, CVD, and CKD, it means that in these patients; the ACE2 activity is increased and may give COVID-19 an easier access into the cell. Even though the effects of ACEis and ARBs in NCD patients with COVID-19 are not conclusive yet, the results are promising and there is a great need to see their relationship to this virus. 10 Herein, in this review, we will discuss how COVID-19 infection plays a role in patients diagnosed with the different types of NCDs and the severity it may cause on them.

| Information source and search criteria
A comprehensive search was performed in PubMed and Scopus databases between December 2019 and January 2022. The following keywords were used: ("covid 19" or "COVID 19" or "sars Cov 2" or "coronavirus" or "corona virus") and ("non communicable diseases" or "non communicable disease" or "NCD" or "NCDs" or "chronic illnesses" or "chronic diseases") as well as ("covid 19" or " COVID 19" or "sars Cov 2" or "coronavirus" or "corona virus") and ("diabetes" or "cardiovascular diseases" or "hypertension" or "cancer" or "kidney disease"). Cochrane and Database of Abstracts of Reviews of Effectiveness databases were also checked for any systematic reviews. All non-English publications were excluded. References from included papers were also screened for studies that might be relevant.

| COVID-19 and obesity
Eating habits have been changed during the pandemic, where people either lost or gained weight. This caused an obesity epidemic, which happens when a large number of the population gains weight due to the consumption of high caloric processed foods. 13 This may also be related to stress, depression or other reasons caused by government restrictions. 14 Simonnet et al. reported that infection with COVID-19 was seen in people with a higher body mass index (BMI) causing to a greater probability of needing a ventilator. 15 This means that more obese patients end up in the intensive care unit (ICU) compared to healthy weighted patients. Furthermore, a report showed the mortality risk was increased among younger COVID-19 infected patients with a BMI ≥ 40 kg/m 2 . 16 Higher mortality rates were also reported in 30 different studies that looked at obese patients infected with COVID-19. 8 Denson et al. 17 reported that 88% of patients who complained of metabolic syndrome while infected with COVID-19 were obese. Obesity may result in the diagnosis of diabetes, hypertension, CVD, stroke, or even cancer. 18 In comparison to other patients, these patients have a higher risk of COVID-19 complications and are more likely to require hospitalization and mortality. However, there is still a need for more research to better understand the mechanism between COVID-19, an increased BMI, and obesity. 9 (Table 1).

| COVID-19 and hypertension
Hypertension was a common comorbidity found in severe and fatal COVID-19 cases. 3 In literature, 97% of metabolic syndrome patients infected with COVID-19 had hypertension, which may increase risk of hospitalizations and mortality. 17 COVID-19 virus enters the body and then the spike protein S attaches to the cells through the ACE2. The major prevalence in hypertension is that the RAAS in hypertensive patients is dysregulated and they usually take drugs that contain ACEis to regulate it, which may or may not increase the ACE2 activity. 6

| COVID-19 and diabetes
Several epidemiological reports consider diabetes as one of the key comorbidities linked to COVID-19 and affecting its severity. 22 Diabetes as a distinctive comorbidity is associated with increased infection of influenza, pneumonia, and acute respiratory distress syndrome, which leads to a three times higher (7.3%) fatality rate (2.3%) of COVID-19. 3,9,[23][24][25][26] According to several reports, the percentage of COVID-19 patients who have diabetes ranges from 14% to 44%. [27][28][29][30] When epidemiologists compared diabetic and nondiabetic patients, they found that diabetic patients have a significantly reduced chance of survival or recovery, also they have a considerably higher chance of developing a serious disease progression. 2 92% of patients with metabolic syndrome had diabetes, these patients had higher rates of hospitalizations and deaths than others, whether they only had diabetes or a combination with other comorbidities. 17 The ACE2 has a lower expression in diabetic patients because of glycosylation. As mentioned above, hypertensive patients have ACEis in their drugs which is also found in diabetic patients' drugs. Diabetic patients have very similar reactions to COVID-19 as hypertensive patients because the drugs they use result in the same reactions in the body. Thus, using ACE2 stimulating drugs would give an easier entry for COVID-19 into the cells and cause more severe and fatal diseases. 31 It also shows that diabetic patients with both micro and macro vascular complications were related to an increased risk of insert of intubation and early passing on the seventh day of being hospitalized. 22,24 Several reports have shown the significant relationship between diabetes and their outcome, for example, Yan et al. 32 reported that diabetic patients have a less survival rate than nondiabetic patients, also found RR of dying (3, 95% CI = 1.3-6.8). Similarly, based on another study in Mexico, diabetic patients infected with COVID-19 have longer hospitalization and poor results, some existing research reviews support these conclusions. 33 The risk of severity among diabetic patients infected with COVID-19 is high and has been reported by Du et al. 34  Additionally, Lu et al. 36 found that risk factors of mortality among diabetic patient and comorbidity are (OR = 3.7, 95% CI = 2.4-5.9). On another hand, Awortwe et al. 23

| COVID-19 and liver disease
The liver remains one of the most vital organs in the human body, it plays an essential role in immunoglobulins production, and among other important functions, it supports the immune system. 44  . However, another systematic review found conflicting evidence, they did not find any significant association between mortality in COVID-19 patients and CLD. Therefore, it is recommended conducting further studies to further investigate the association between CLD and COVID-19.

| COVID-19 and asthma/COPD
The novel coronavirus targets the respiratory system, which causes acute respiratory disease that may lead to respiratory failure, pneumonia, and death. 49 This raises major concerns about patients who live with CLD such as asthma and COPD. This should push researchers to study the interaction of these diseases with AL-QUDIMAT ET AL.

| COVID-19 and cancer
Cancer has become one of the main factors contributing to mortality and morbidity in the last few decades, with various forms and types.  58 This confirms that cancer patients are one of the most exposed groups to suffer the devastating outcomes of COVID-19 and highlights the importance of applying prophylactic measures to protect them from the disease.

| DISCUSSION
People gain weight when the calories consumed is higher than the calories getting burned in the body, in other words, when the food exceeds the energy expenditure. 59 Without physical activity and sitting for a long period of time contributes to the risk of weight gain. 60 In the wake of the COVID-19 pandemic, many countries have recommended that people stay at home as a primary means of limiting human exposure to the virus and thereby limiting its spread.
As a result of decreased physical activity, changes in food consumption, and the stress involved with adjusting to a new situation, weight change may be a possibility during the quarantine period. According to a study conducted in Poland with 59,711 total subjects from 32 countries to examine the impact of COVID-19's first lockdown on body weight, body weight changes were reported by 11.1%-72.4% of those polled, with the majority reporting an increase in body weight after or during the lockdown period. 61 The most significant rise in body weight was discovered in an Iraqi study in which 45.6 percent of participants were between the ages of 21 and 30 years old. 62 An Increase in the population's body weight during lockdown is due to a range of variables, including lifestyle, eating habits, and physical activity changes. 63 In an astonishing nationwide broadcast, it is stated that, during the COVID-19 outbreak, a bad prognosis was associated with the presence of a comorbid factor, one of which was very severe hypertension. 64 According to the findings of the studies, anxiety and hypertension were highly related, and anxiety was found to be an independent risk factor for the development of incident hypertension. 65 As per Zuin et al. 66 , a systematic evaluation of 419 individuals discovered that hypertension was the most common comorbidity associated with the virus. Patients with COVID-19 infections with a high blood pressure had a significantly greater risk of death when compared to patients with normal blood pressure.
Another study, conducted in January 2020, found that 11 out of 99 individuals with COVID-19 died, with three of those patients having high blood pressure. 67

ACKNOWLEDGMENT
The publication of this article was funded by Qatar National Library.

CONFLICT OF INTEREST
The authors declare no conflict of interest. Dr. Abdulqadir Nashwan is an Editorial Board member of Health Science Reports and a coauthor of this article.

DATA AVAILABILITY STATEMENT
The data that supports the findings in this study are available from the corresponding author upon reasonable request.

TRANSPARENCY STATEMENT
The corresponding author, Raed M. Al-Zoubi, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.